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STATE OF CALIFORNI#& WATER RESOURCES CONTROWARD <br /> FORM 'B': UNDE GROUND STORAGE TANK PROGRAM m <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEWPERMIT F-13 RENEWALPERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDEDPERMIT 6 TEMPORARYTANK CLOSURE 0B TANK REMOVED <br /> Fla <br /> T—r ,( FARM TANK-YE8❑ NO <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: /��_ �/ Z <br /> e0 <br /> 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWN-80 ECI <br /> A. OWNERS TANK ID# �L,ci �_70777F. MANUFACTURED BY: f� <br /> C.YEAR INSTALLED a� D. TANKCAPACITYIN GALLONS: QQ CA) <br /> 11. TANK CONTENTS IF(A.1),I ARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED SEL <br /> 3 CHEMICAL PRODUCT 4 OIL PRODUCT ❑4 GASAHOL � 5 JET FUEL 6 AVIATION GAS <br /> Ej5 HAZARDOUS BO EMPTY ❑95 UNKNOWN 2 WASTE 7 METHANOL <br /> []99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ! fr C.A.S.#: a <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> [q. <br /> TYPE OFF <br /> �3 SINGLEWALLFDWITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 4 SECONDARY CONTAINMENT 99 OTHER <br /> �2 STAINLESS STEEL 03 FIBERGLASS 4 STEEL CLAD WNIBERGLASS REINFORCED PLASTIC <br /> TANK 6 POLYVINYLCHLORIDE F 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> MATERIA10 GALVANIZED STEEL 0 95 UNKNOWN 99 OTHER <br /> 11RUSBERUNED 2A OUNING 3EPDXY UNING 4PHENOUC LINING <br /> C. INTERIORN 5 GLASS UNING 6 UNLINED [:j95 UNKNOWN <br /> ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [—] NO 99 OTHER <br /> D. CORROSION ❑ 1 POLYEfHLENEWRAP 2 TA ASPHALT 3 VINYLWRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 1 NGNE E]95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A(1)95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <br /> C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 9100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A3-, 594 <br /> UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 5 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P PRECISION TESTING P 3 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> . ESTIMATED QUANTITY Of 3.WAS TANK BILLED WITH <br /> 2 <br /> 1.ESTIMATED DATE LAST USE ( / ) SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? 0 YES E] NO <br /> THIS FORM HAS RE N COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> 3 � / 3 0o v <br /> CURRENT LOCAL CY FACILITY # <br /> APPROVED BY NA E PHONE#WITH AREA CODE <br /> 1 PERMIT NUMBER /,'7�'�•p✓ G PERMIT APPROVAL DAT FERMI PIRATION DATE . <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> ORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIE A FACILITY DIA A PROCESSING ATIoN, ORMO 'A',UNLESS A ,. RENT FORMA' HAS BEEN FILED <br />